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Evaluating Claims Documents


January 31, 2008   by


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As information from a claims investigation accumulates, the adjuster is always evaluating and re-evaluating the claim as a whole, searching for a fair outcome. Any reports or documentation must be carefully reviewed in order to substantiate the claim. The following article will provide you with some ideas to consider the next time you are reviewing claims documentation.

Ideally the insured will submit receipts or provide visual documentation of the more expensive items in the claim.

Receipts

The adjuster must be satisfied that submitted documentation is authentic. The adjuster should know under what circumstances the receipts were obtained. Was the retailer asked to reproduce receipts in order to present the claim? Perhaps the retailer could be asked to verify that an item was purchased. A credit card statement could be used to verify a purchase.

Any reproduction of documentation with the intent of defrauding the insurer is of concern. Fraud in insurance has been perpetrated by insured’s producing receipts that actually belong to someone else. The documentation appears authentic in all ways, except that the insured did not make the purchase and never owned the property. Or, the insured may have purchased the item to get a legitimate receipt, intending to return the item to the store. In any case, an original receipt is preferred rather than a photocopy because it is easier to alter a copy.

Invoice numbers can be revealing. When the insured provides several invoices with several different dates, yet the invoice numbers are in sequence, the receipts are probably bogus.

Overall, invoices should be checked for accuracy. Is the tax charged the appropriate percentage in relation to the date of the purchase? Are other calculations correct?

Visual Documentation

The scene of an accident or loss provides information to clarify or confirm the details of the claim. Evidence from the scene of the loss may be documented with diagrams that include measurements and dimensions, photographs or a video recording.

Photographs, videotapes and any other such documentation have many purposes. They remind people of what an area looked like; they may enhance any physical evidence; they may record the lack of physical damage, or the extent of damage, and the general type and quality of goods; and they provide an inexpensive way to document evidence.

The insured may offer photographs to validate the existence of stolen or destroyed property. This is an excellent source of information, however, adjusters must analyze photographs carefully to validate their authenticity.

Example

The insured lamented to the adjuster that a sophisticated and expensive piece of boat equipment had been stolen. A picture of the boat was produced showing the installed equip- ment. Upon further investigation, the adjuster discovered that the insured had pasted advertising material on his boat and then took a picture. The boat was examined and it was proven that the “stolen” equipment had never been installed.

When discrepancies are found, the adjuster should investigate. It is a crime to produce false documentation in order to get an insurance payment.

Whenever evidence is to be evaluated, the credibility of witnesses and claimants plays an important part. Judges ask jurors to weigh testimony against its inherent probability or improbability in order to test its credibility. There are two elements to the issue of credibility: (1) the information disclosed, and (2) the impression the witness makes. The following example depicts a scenario where the adjuster was able to prove a fraudulent claim through a thorough evaluation of claim documentation.

Example

Bill submitted a claim for theft from his storage locker that included a set of speakers purchased in November 1994 from a private individual for $10,000. This was an unusually high value for speakers. The adjuster expressed concern, in writing, that documentary evidence of the value of the speakers had not been provided. Sometime later Bill produced his own receipt copy from his receipt book for the speakers made out to the seller in 1994, when the speakers were purchased.

When the adjuster asked how he paid for the speakers, Bill said he paid cash. He claimed that he habitually kept large amounts of cash at his home. Bill had not made any withdrawals from his bank nor did he have credit card records for such a purchase.

The adjuster contacted the manufacturer of the receipt book and was told that the book was not put on the market until 1995. The manufacturer could not guarantee this fact, but believed it to be true. Bill stood his ground and continued to assert that the speakers were bought in 1994.

Later the manufacturer was able to provide conclusive proof that the receipt book was released in the market n 1995. Bill changed his position. He said he now recalled that he had actually purchased the speakers in 1995 and that he must have made a mistake about the date on the receipt.

When the claim was denied, Bill sued the insurance company. The judge did not accept Bill’s proof relating to the speakers. The judge commented that the flow of unfortunate circumstances defied the laws of probability.

The insurer was able to demonstrate how improbable the information was in order to defeat the claim.

Whenever suspicions are raised, a thorough investigation is warranted.

When the claimant responds to the issues of concern, the adjuster can then evaluate whether the circumstances have been adequately clarified. With a thorough evaluation of claims documentation, the adjuster will be better equipped to provide a fair assessment of the claim.

This article is based on excerpts from the study material in the Claims Professional Series of applied courses — a core of the CIP Program that helps adjusters learn the functional knowledge and skills required of their profession.